Get Cancer Now, Before Congress Cuts Your Insurance

By Justin Ordoñez

June 23, 2017

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Sam Cannon

SEATTLE — I’m 35 years old. I didn’t go to college after high school. Instead I got a job in insurance, and I’ve spent half my life on the business side of keeping people healthy. Only once have I felt that the industry took positive steps toward insuring America, and that was when Obamacare mandated it.

I assumed Donald Trump’s presidency would doom the law. A Republican replacement, which could cut off insurance for millions of people, could pass the Senate as soon as next week. And I fear that most Americans, who don’t really worry about their health until they get sick, won’t be willing to fight against it.

Only when you’ve done what I’ve done will you understand what will happen if the Republicans destroy Obamacare.

My first job in the industry was at a company that helped businesses administer their employees’ insurance benefits. It needed people to man the call center during the open enrollment season, when those lucky enough to have insurance through their jobs made coverage elections for the coming year. I had no experience, but I smiled when I thought it was appropriate and tried to look as if I belonged.

I had thought America was a country where people made choices for themselves. The training course taught me that, on the contrary, people typically obtained health insurance from their employer and had the cost and the coverage largely dictated to them. I learned about “pre-existing conditions,” a term that would soon be notorious. I paid attention because, although I was 19, I already knew that I would eventually need to have my hip replaced. If I had a break in medical coverage, I could be facing those costs on my own.

The job got tedious quickly. When one major corporation stopped covering Viagra, the service center was flooded with calls. One of my colleagues tore off her headset, shouting, “I can’t talk to old men about erections any longer!”

After open enrollment ended, the calls became more serious. They came from all around the country. A man asked to switch plans because his wife desperately needed treatment at an out-of-network clinic. Parents had delayed adding newborn children to their policy and now worried they couldn’t get coverage. The answers I gave were based not on steadfast rules and regulations but on the generosity of the callers’ employer — some people I could help, others I had to hurt.

Our database gave me the callers’ age, race, gender, date of hiring, spousal and dependent information, current coverage and hourly wage or salary. I developed a habit of crunching numbers to pass the time. A female caller made, say, $21,840 a year with a monthly premium of $225, leaving her with $19,140. Like me, she had injured her hip. Add up her deductible, co-payment, likely hospital bills, prescriptions, physical therapy and a few weeks of missed work, and she had less than $13,500 left over. I would be at my desk, thinking: “My rent is $685 a month. What’s hers?”

My next job was as a workers’ compensation claims examiner. Many claims had vague accident descriptions and no witnesses. I had one claimant, a data-entry clerk, file for wrist pain caused by carpal tunnel syndrome after having been employed for only a few days. When asked if she had experienced any symptoms before, she never wavered: “No.” Her surgeries were covered.

I was surprised, and not. I had been doing the math. It never added up. For many of these people, the only way they were going to get the care they needed was to feign being injured at work.

In workers’ comp, doctors were passive, employers were punitive, employees juiced the system, and I had to close cases. I found a physician at an independent medical examination company who almost always signed off on my cases, as long as they included appropriate leading data. I referred to him as “Dr. Fixed and Stable.” (“Fixed and stable” basically meant a patient had received sufficient treatment; it was the magic term that allowed me to close a claim.) I never met this doctor, but I sensed he was down with the game. We paid him a few hundred dollars a pop, and my cases got closed.

In 2007, I decided to give college a shot. I needed a flexible work schedule, but because of my pre-existing condition, I couldn’t let my insurance lapse. I found a job with benefits at a smoking cessation company, working nights and weekends.

Funded mostly by the ’90s tobacco settlements, the stop-smoking hotlines helped everyone, not just those with insurance or those who could manipulate the system. But luck still played a role. Radio commercials would air promising free samples of patches and gum. The phones lit up, but the samples soon ran out. I thought: Why is acquiring health care like visiting a casino? Why does it feel as though you have to win to get it?

Then Barack Obama was elected. He spent his presidency building and defending the Affordable Care Act. It was ambitious legislation, but I was concerned. The employer-driven insurance industry had no clue how to provide sufficient health care to the people who were already insured. Now we needed to include the uninsured, too?

In 2012, I had the hip replacement — a $44,000 procedure. Thankfully, I had kept my insurance coverage, as the A.C.A. wouldn’t prohibit pre-existing condition exclusions until 2014. I am still amazed that losing insurance for two months could have excluded me from medical care forever. I was proud that America would no longer be a country where a 19-year-old wondered if a lapse in insurance would leave him crippled.

Also thanks to the A.C.A., I began buying my insurance through my state’s health care exchange website. Like the healthcare.gov site, it had a rocky start and was widely panned, but I loved it. It was an actual marketplace and not a shadowy industry where brokers and H.R. departments hammered out deals. I had several insurers offering me coverage, with transparent plan information and pricing. It was almost as if they were competing.

And still, I worried. With this new transparency, people would see the blemishes in the industry. What would they blame for these flaws, the new law or the system it was designed to repair?

When the marketplace was unable to transfer enrollee information from its computers to the health care insurers, it was viewed as a failure of government. But all my colleagues had war stories about failed data feeds. Getting these systems to communicate could be so difficult that sometimes companies didn’t even try; they hired people to re-enter the information manually.

By now I had moved on to a new job focused on Medicaid clients, which meant I encountered a pillar of Obamacare, the Medicaid expansion. Many more chronically ill people were now being covered by the government. This was my opportunity to see the costs of uninsured America, a giant pool of liability so muddied by the complexities of coding and poor data tracking that no one knew if it was two or 20 feet deep. I suspected America was far sicker than the politicians described.

One issue that stood out was the number of patients who had contracted sepsis, a blood infection. Unable to get medical care, patients had lived with infections for weeks, maybe months, until bacteria caught a ride into their blood streams. Now Medicaid was paying bills as large as $100,000, and those patients who did not die were facing months of recovery, and not a premium payment had been made to compensate for it.

President Trump has portrayed Obamacare as a cesspool. The problem was never Obamacare. It was uninsured America — people who had been cut out of the system, but who were nonetheless pushing us toward collective bankruptcy. Obamacare just cleaned the water enough for us to finally see the time bomb in the depths.

Republican plans to fix health care simply put mud back into the pool, finding new ways to stop covering sick Americans. Medicaid rolls will shrink again; insurers in certain states may cut what they cover. Even pre-existing conditions could become a problem again. While the draft of the Senate bill still technically requires insurers to cover these patients, it would let states petition to limit that coverage — who knows by how much. And the House version would let insurers charge them much more, putting private insurance out of reach for many.

In the short term, all this is beneficial from the industry’s perspective. It’s easier to balance the books if you don’t count the sick. In the long term, everyone gets sick, and for those people to be profitable, they need to be making premium payments throughout their entire lives — not just when they’re sick and not just when they have a job that offers benefits. This is why no health care legislation can work if it drops the mandate to buy coverage, as both the House bill and the draft of the Senate bill do.

When you work in insurance, patients become statistics. At 2:30 on a Thursday afternoon, when I’m slouched in my chair, looking at my 20th case of the day, am I envisioning a person? No. I see white, female, 40s, Medicaid recipient, with a request for Code 77059, bilateral breast M.R.I., and I hope it isn’t cancer, but I can’t linger. Sentimentality is another form of inefficiency. That’s how I’ve survived my first decade and a half in this industry, and I suppose that’s how I’ll survive however long I remain.

But when I think of an America without Obamacare, I feel the weight of a human tragedy that is so much larger than the thousands of individual tragedies I’ve taken part in. I want to believe Americans will come to their senses, but I doubt it. The America I know is a place where you have to fake an injury at work to get treatment, where you have to hear a radio commercial at the right time, where you need a Dr. Fixed and Stable. There’s a madness to it that will drive you insane if you let it. This isn’t an industry. It’s a lottery.

White/female/45 looking for 77059? If it is cancer, she’s lucky she got it now, before her government decides to cut off her health insurance. She’s lucky she won the lottery.

Justin Ordoñez works for a health care consulting company.

A version of this article appears in print on , on Page SR1 of the New York edition with the headline: I Am the Man Who Denied Your Claims. Order Reprints | Today’s Paper | Subscribe